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MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 10

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Mississippi Last updated 01/04 2021 Section C . Additional Factors of Eligibility for Separate CHIP Eligibility Factor Self- Attestat ion Accepte d without Additio nal Verificat ion Self- Attestatio n Accepted with Post- Enrollmen t Verificatio n (Y/N) Electroni c Data Source Used (Y/N) If Yes, please describe in commen ts Paper Document ation Required from the Individual (Y/N) Non- Applicable (N/A) Comments 1. Applicant does have other coverage not YES NO NO N O Must be Applied When other coverage is reported by other sources, such as providers, it is resolved. cases a reasonable explanation or paper documentation is requested, if necessary. In such 2. Applicant does have access to afforda ESI not ble N/A NA to MS CHIP 3. When child has had coverage (as applicable to states' waiting period) N/A 4. Access to public employee coverage N/A 5a. Waiting period exception #1 (describe): N/A 5b. Waiting period exception #2 (describe): N/A 5c. Waiting period exception #3 (describe): N/A 5d. Waiting period exception #4 (describe): N/A 5e. Waiting period exception #5 (describe): N/A 5f. Waiting period exception #6 (describe): N/A